Rupesh Agrawal1, Ilaria Testi2, Sarakshi Mahajan3, Yew Sen Yuen4, Aniruddha Agarwal5, Onn Min Kon6, Talin Barisani-Asenbauer7, John H Kempen8, Amod Gupta5, Douglas A Jabs9, Justine R Smith10, Quan Dong Nguyen11, Carlos Pavesio2, Vishali Gupta12. 1. National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Republic of Singapore; Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, United Kingdom; Singapore Eye Research Institute, Singapore, Republic of Singapore; School of Material Science and Engineering, Nanyang Technological University, Singapore, Republic of Singapore. 2. Moorfields Eye Hospital and Biomedical Research Centre, Institute of Ophthalmology, University College London, London, United Kingdom. 3. St. Joseph Mercy Hospital, Oakland, Pontiac, Michigan. 4. Department of Ophthalmology, National University Hospital, Singapore, Republic of Singapore. 5. Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 6. Chest and Allergy Clinic, St. Mary's Hospital, Imperial College Healthcare Service Trust, London, United Kingdom. 7. Centre of Ocular Inflammation and Infection, Laura Bassi Centre of Expertise, Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria. 8. Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts; Eye Unit, MyungSung Christian Medical Center, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia. 9. Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Wilmer Eye Institute, Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland. 10. Flinders University College of Medicine and Public Health, Adelaide, Australia. 11. Byers Eye Institute, Stanford Medical School, Stanford, California. 12. Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Electronic address: vishalisara@yahoo.co.in.
Abstract
TOPIC: An international, expert-led consensus initiative organized by the Collaborative Ocular Tuberculosis Study (COTS), along with the International Ocular Inflammation Society and the International Uveitis Study Group, systematically developed evidence- and experience-based recommendations for the treatment of tubercular choroiditis. CLINICAL RELEVANCE: The diagnosis and management of tubercular uveitis (TBU) pose a significant challenge. Current guidelines and literature are insufficient to guide physicians regarding the initiation of antitubercular therapy (ATT) in patients with TBU. METHODS: An international expert steering subcommittee of the COTS group identified clinical questions and conducted a systematic review of the published literature on the use of ATT for tubercular choroiditis. Using an interactive online questionnaire, guided by background knowledge from published literature, 81 global experts (including ophthalmologists, pulmonologists, and infectious disease physicians) generated preliminary consensus statements for initiating ATT in tubercular choroiditis, using Oxford levels of medical evidence. In total, 162 statements were identified regarding when to initiate ATT in patients with tubercular serpiginous-like choroiditis, tuberculoma, and tubercular focal or multifocal choroiditis. The COTS group members met in November 2018 to refine these statements by a 2-step modified Delphi process. RESULTS: Seventy consensus statements addressed the initiation of ATT in the 3 subtypes of tubercular choroiditis, and in addition, 10 consensus statements were developed regarding the use of adjunctive therapy in tubercular choroiditis. Experts agreed on initiating ATT in tubercular choroiditis in the presence of positive results for any 1 of the positive immunologic tests along with radiologic features suggestive of tuberculosis. For tubercular serpiginous-like choroiditis and tuberculoma, positive results from even 1 positive immunologic test were considered sufficient to recommend ATT, even if there were no radiologic features suggestive of tuberculosis. DISCUSSION: Consensus guidelines were developed to guide the initiation of ATT in patients with tubercular choroiditis, based on the published literature, expert opinion, and practical experience, to bridge the gap between clinical need and available medical evidence.
TOPIC: An international, expert-led consensus initiative organized by the Collaborative Ocular Tuberculosis Study (COTS), along with the International Ocular Inflammation Society and the International Uveitis Study Group, systematically developed evidence- and experience-based recommendations for the treatment of tubercular choroiditis. CLINICAL RELEVANCE: The diagnosis and management of tubercular uveitis (TBU) pose a significant challenge. Current guidelines and literature are insufficient to guide physicians regarding the initiation of antitubercular therapy (ATT) in patients with TBU. METHODS: An international expert steering subcommittee of the COTS group identified clinical questions and conducted a systematic review of the published literature on the use of ATT for tubercular choroiditis. Using an interactive online questionnaire, guided by background knowledge from published literature, 81 global experts (including ophthalmologists, pulmonologists, and infectious disease physicians) generated preliminary consensus statements for initiating ATT in tubercular choroiditis, using Oxford levels of medical evidence. In total, 162 statements were identified regarding when to initiate ATT in patients with tubercular serpiginous-like choroiditis, tuberculoma, and tubercular focal or multifocal choroiditis. The COTS group members met in November 2018 to refine these statements by a 2-step modified Delphi process. RESULTS: Seventy consensus statements addressed the initiation of ATT in the 3 subtypes of tubercular choroiditis, and in addition, 10 consensus statements were developed regarding the use of adjunctive therapy in tubercular choroiditis. Experts agreed on initiating ATT in tubercular choroiditis in the presence of positive results for any 1 of the positive immunologic tests along with radiologic features suggestive of tuberculosis. For tubercular serpiginous-like choroiditis and tuberculoma, positive results from even 1 positive immunologic test were considered sufficient to recommend ATT, even if there were no radiologic features suggestive of tuberculosis. DISCUSSION: Consensus guidelines were developed to guide the initiation of ATT in patients with tubercular choroiditis, based on the published literature, expert opinion, and practical experience, to bridge the gap between clinical need and available medical evidence.